Central Consultation Register Information Form

KEMPSEY SHIRE COUNCIL
Civic Centre, Cnr Elbow & Tozer Streets, Kempsey 2440
PO Box 78, West Kempsey 2440
Phone 02 6566 3200 Fax 02 6566 3205
Web: www.kempsey.nsw.gov.au Email: ksc@kempsey.nsw.gov.au

CENTRAL CONSULTATION REGISTER INFORMATION SHEET

Name*:

Address*:

Town/Village/Area*:

Phone:

(H): (W): (Mbl):

Email:

Occupation*:

Gender*:

Male Female

Age Range*:

15-19 yrs 20-29 yrs 30-39 yrs 40-49 yrs 50-59 yrs 60+ yrs

Indigenous Status:

Indigenous non-Indigenous

Preferred Meeting Time:

Morning Afternoon Evening

Community Interests*:

Organisations of which you are a member*:

Hobbies*:

Disclosures:*

Disclosures include details of relevant relationships, contacts, commitments, affiliations with Kempsey parties where conflicts of interest, commercial compromise or confidentiality issues may arise. Consultation opportunities will not unreasonably be affected as a result of any or all disclosures provided.

* Indicates that information must be entered

Consent:

Please include me on Kempsey Shire Council's central consultation register. I am happy to be contacted by Council at any time to see if I am interested in participating in a focus group or other community consultation.

Privacy Statement:

Council collects and holds personal information for a number of reasons related to Council business, eg to process applications, to issue rate notices, to process correspondence. When you provide personal information to Council it is used in accordance with privacy laws applicable to Council. Your personal information will only be used for purposes related to the business of Council.